Laparoscopic surgery during pregnancy

Ovarian Torsion at 8 weeks of Gestation in a Woman with Threatened Abortion After Frozen-Thawed Embryo Transfer: A Case Report

Introduction

Ovarian torsion during pregnancy is a rare condition that requires prompt diagnosis and repositioning to preserve ovarian function.

Case Report

A 32-year-old woman underwent a successful pregnancy after FET, but was hospitalized for observation because of a threatened abortion. During the 8th week of pregnancy, a transvaginal ultrasound examination was performed due to sudden lower abdominal pain, which displayed an 8.3×5.2cm right ovary and a 4.3×3.6 cm enhanced echogenic mass over the right ovary with striated structures. Consequently, a preliminary diagnosis of ovarian torsion was made, and urgent laparoscopic exploration was conducted. Intraoperatively, the right fallopian tube and right ovary were rotated counterclockwise by 720 degrees. After rotate and reposition the right ovary and fallopian tube, a 3 cm diameter cyst was punctured. After 1 hour of observation, a 2×1×1cm segment of ovarian tissue was excised. Pregnancy was maintained with aggressive postoperative luteal support and anti-infective treatment.

Conclusion

The use of clomiphene citrate during endometrium preparation for frozen-thawed embryo transfer cycles may elevate the risk of ovarian torsion. Laparoscopic ovarian repositioning after ovarian torsion in pregnant women, even those with threatened abortion, is safe when combined with postoperative anti-infective treatment and intensive luteal support.

Dermoid cyst management and outcomes: a review of over 1000 cases at a single institution

BACKGROUND

Mature cystic teratomas represent nearly 60% of benign ovarian neoplasms across all age groups.

OBJECTIVE

This study aimed to update existing descriptive studies of ovarian teratomas, including the epidemiology, rate of torsion or malignancy, and treatment modalities in a large modern cohort of patients.

STUDY DESIGN

This was a retrospective cross-sectional study of all pathology-confirmed cases of ovarian teratoma that underwent surgery at 1 tertiary care institution from 2004 to 2015. Patient demographics, ovarian cyst characteristics, surgical approach and timing, rate of spillage, and surgical complications were examined.

RESULTS

A total of 1054 cases of ovarian teratoma were identified during the study period. There were 113 cases (10.7%) of bilateral teratoma. The mean age at diagnosis was 38 years. The average cyst size was 6.26 cm. The overall rate of torsion was 5.6%, with a higher rate of torsion with increasing cyst size. More than 70% of cases were treated with minimally invasive surgery, which was associated with decreased perioperative complications but an increased risk of cyst spillage. Among 394 patients with cyst spillage, only 1 patient developed chemical peritonitis. The malignant transformation rate of mature cystic teratoma in this cohort was 1.1%. This cohort included 100 pregnant women with mature teratoma. Pregnant patients were more likely to have minimally invasive surgery in the first trimester of pregnancy and more likely to undergo laparotomy in the second or third trimester of pregnancy.

CONCLUSION

Similar rates of bilaterality, torsion, malignant transformation, and struma ovarii in ovarian teratomas were found in this large modern cohort compared with previous literature. Most cases of ovarian teratoma can be managed laparoscopically, which is associated with a lower surgical complication rate. Despite the increased risk of cyst spillage with a minimally invasive approach, chemical peritonitis is a rare complication.

Surgical Management of a Torn ACL and Bucket-Handle Meniscal Tear in the Pregnant Patient: A Case Report

CASE

A 36-year-old, 7-month pregnant woman presented to the office with a locked knee and a displaced bucket-handle medial meniscus tear, in the setting of chronic anterior cruciate ligament (ACL) insufficiency. After thorough discussion with the patient and her husband, the obstetrician, and the anesthesiologist, the patient was treated with left knee ACL reconstruction and medial meniscus repair.

CONCLUSION

With sufficient preoperative planning and coordinated multidisciplinary care among orthopaedic, anesthesiologist, and obstetric specialists, elective knee surgery can be performed safely in time-sensitive situations during pregnancy.

A pregnant woman with long-standing, retained intraabdominal glass shards who gave birth to a live infant with no complications: a case report

BACKGROUND

Most cases of traumatic injury during pregnancy involve blunt trauma, with penetrating trauma being uncommonly rare. In glass shard injuries, fragments often penetrate deeply, and multiple injuries may occur simultaneously; attention must be paid to the possibility of organ injury from the residual fragments. However, no case of this occurring during pregnancy has been reported yet.

CASE PRESENTATION

We present the case of a 34-year-old pregnant Cameroonian woman who retained intraabdominal glass shards following a penetrating injury at 13 weeks gestation and not diagnosed until 22 weeks gestation. Notably, this patient continued the pregnancy without complications and gave birth via cesarean section at 36 weeks gestation.

CONCLUSION

In pregnant women sustaining a penetrating glass trauma during pregnancy, careful attention should be paid to the fragments; in that case, computed tomography is a useful modality for accurately visualizing any remaining fragments in the body. Essentially, the foreign bodies in glass shard injuries during pregnancy should be removed immediately, but conservative management for term delivery is an important choice for patients at risk for preterm delivery.

Laparoscopic management of ovarian cysts during pregnancy under urgent situations

BACKGROUND

Majority of adnexal masses are incidental findings during pregnancy and resolve spontaneously. They may complicate pregnancy due to haemorrhage, cyst rupture and ovarian torsion. Laparoscopy is the preferred surgical intervention owing to shorter operative time, quicker recovery and lower post-operative pain. However, safety and feasibility of laparoscopic surgery in the management of ovarian cysts in pregnant women is challenging especially at advanced gestational ages and in urgent situations.

METHODS

In this retrospective study, a total of 48 cases of urgent laparoscopic surgeries were evaluated in the first and second trimesters of pregnancy between March 2018 and March 2021 in Al-Zahra Hospital, Tabriz, Iran.

RESULTS

The operations were ended in all patients successfully. The mean operation time was 45 min. There were no foetal maternal complications. All pregnancies had been terminated after 37 weeks of gestation. Oophorectomy had been performed in six patients and six other patients needed blood transfusion. Ovarian torsion was the most common reason for emergency surgery and mature teratoma was the most commonly reported pathology. Tocolytic therapy was required in six patients, and all of the patients were prescribed 50 mg of injectable progesterone twice daily for 10 days after surgery. The mean intra-abdominal pressure was equal to 15 mmHg and the mean end-expiratory carbon dioxide (CO 2 ) pressure was 36 mmHg. Intravenous paracetamol was used to relieve post-operative pain. The mean hospitalisation time was 1.63 days.

CONCLUSION

Most of the ovarian cysts can be managed laparoscopically with ensured safety and lower morbidity even in emergency situations at advanced gestational ages.

General Surgery During Pregnancy and Gynecologic Emergencies

Nonobstetrical surgical emergencies can occur throughout pregnancy but are often difficult to diagnose due to the physiologic and anatomical changes that occur during pregnancy. Medical providers should have insight into these changes and be familiar with options for the diagnosis and management of common nonobstetrical surgical emergencies, such as appendicitis, cholecystitis, and small bowel obstruction. Surgeons should also be aware of obstetrical emergencies, such as ectopic pregnancy and severe vaginal bleeding, which may be life threatening to mother and the fetus. Intraoperatively, surgeons should be familiar with minimally invasive approaches for surgical diseases and special anesthetic considerations for pregnant patients.

Meckel's Diverticulum as a Cause of Small Bowel Obstruction Complicated with Gangrene in the Third Trimester of Pregnancy: A Case Report

Acute abdomen during pregnancy is rare. Despite advances in diagnostic imaging, preoperative diagnosis in the pregnant population due to anatomical and physiological changes can pose difficulties. Diagnosis and surgery delays increase the risk of adverse outcomes for both maternal and fetal health. In symptomatic cases, explorative surgery might be essential for correct diagnosis and patient treatment. Here, we present Meckel's diverticulum as an unusual cause of small bowel obstruction complicated with gangrene in a 34-week pregnant patient. The diagnosis was only apparent during explorative surgical laparotomy.

[Laparoscopic appendectomy for acute appendicitis in pregnancy]

The review is devoted to the role of laparoscopic appendectomy in surgical management of acute appendicitis in pregnancy. We analyzed reviews, prospective and retrospective studies in the PubMed, Google, the Springer Link online library, the Cochrane Systematic Review databases. The results of laparoscopic and traditional treatment of acute appendicitis in pregnant women were assessed. We analyzed clinical, epidemiological features in these patients, differential diagnosis of acute appendicitis in pregnant women, indications and contraindications for endoscopic treatment, features of laparoscopic procedures. Comparative assessment of laparoscopic and open surgeries for acute appendicitis in pregnant women was carried out. We also estimated the influence of surgical treatment of acute appendicitis on subsequent course of pregnancy.

Surgical and obstetrical outcomes after laparoscopic appendectomy during pregnancy: a case-matched analysis

PURPOSE

Laparoscopic appendectomy (LA) for acute appendicitis (AA) remains controversial during pregnancy. We aimed to determine surgical and obstetrical outcomes of LA in pregnant women.

METHODS

Pregnant women who underwent LA for AA (G1) between 2006 and 2019 were included and matched by gender, age, white blood cells, ASA score, and presence of peritonitis in a 1:2 ratio with non-pregnant women who had undergone LA (G2). Demographics and surgical outcomes were compared between groups. Preterm delivery and fetal loss rate were also analyzed.

RESULTS

From a total of 2009 LA, 18 (0.9%) were included in G1 and 36 (1.8%) in G2. There were no intraoperative complications or converted surgeries. Length of hospital stay was longer in G1 (G1: 2.6 vs G2: 1.4 days, p < 0.01). There was no difference in overall morbidity and readmission rates. Fetal loss and preterm delivery rates were both 11%.

CONCLUSION

LA in pregnant women has similar intraoperative and postoperative outcomes as those achieved in non-pregnant patients. In addition, the laparoscopic approach does not seem to jeopardize obstetrical outcomes.

Laparoscopic treatment for appendicitis during pregnancy: Retrospective cohort study

Background

Acute appendicitis is the most frequent non-obstetric surgical emergency during pregnancy. The benefits of laparoscopy during pregnancy are well known, but complications can occur, and these can affect both the mother and/or the foetus.We present results of laparoscopic surgical treatment of acute appendicitis in pregnant women, analysing the occurrence of adverse postoperative, obstetric and foetal outcomes and reviewing literature.

Materials and methods

Retrospective observational study on pregnant women with a preoperative diagnosis of acute appendicitis.

Results

n = 63, mean age 28.4 years, average gestational age of 17.7 weeks (3-30 weeks). 6.4 % exploratory laparoscopies, 92 % laparoscopic appendectomies and one right colectomy were performed. Conversion rate was 3.2 %. When symptoms begun within 48 hours prior to surgery, a perforated appendicitis was found in 11 %; whereas when the time from symptom onset to surgery was greater than or equal to 48 hours, it was evident in 31 % of the cases (p 0.008). The only independent variable associated with the presence of postoperative complications was symptom duration prior to surgery greater than or equal to 48 hours (OR 4.8; 95 % CI 1.1-16.2; p 0.04). Seven minor and 2 mayor postoperative complications were observed. Patients with complications spent, on average, twice as many days hospitalized (p < 0.001); and had 8 times more risk of preterm delivery (p 0.03). Obstetric complications were more frequent in pregnant women operated during the first trimester. Foetal mortality was 1.6 %.

Conclusion

Surgical morbidity of acute appendicitis in pregnant women is linked to the delay in the diagnosis and treatment of the inflammatory condition. Laparoscopic appendectomy during pregnancy is not exempt from postoperative, obstetric and foetal complications. It is necessary to standardize the definitions of "complication" in order to collate reliably the outcomes presented in the literature.

Salpingectomy vs tubal ligation for sterilization: a systematic review and meta-analysis

OBJECTIVE

After strong evidence and major organizations recommending salpingectomy over tubal ligation, we sought to perform a systematic review and meta-analysis comparing the intraoperative attributes and complication rates associated with these 2 procedures.

DATA SOURCES

We searched PubMed, the Cochrane Library, Embase, and clinical trials registries without time or language restrictions. The search was conducted in February 2020. Database searches revealed 74 potential studies, of which 11 were examined at the full-text level. Of these, 6 studies were included in the qualitative analysis and 5 studies were included in the meta-analysis.

STUDY ELIGIBILITY CRITERIA

We included randomized controlled trials comparing salpingectomy with tubal ligation in women seeking sterilization. We included studies that also had at least 1 outcome listed in the population/patient problem, intervention, comparison, outcome, and time. Articles were excluded if they did not meet the inclusion criteria or if data were not reported and the authors did not respond to inquiries.

STUDY APPRAISAL AND SYNTHESIS METHODS

Abstracts and full-text articles were assessed by 2 authors independently using the blinded coding assignment function or EPPI-Reviewer 4. Conflicting selections were resolved by consensus. The quality of included studies was determined using the Cochrane Collaboration tool for assessing the risk of bias in randomized trials. Two authors independently assessed the risk of bias for each study; disagreements were resolved by consensus.

RESULTS

There were few differences between the procedures, with no differences in most important clinical outcomes (antimüllerian hormone, blood loss, length of hospital stay, pre- or postoperative complications, or wound infections). A single study reported a reduced rate of pregnancies with salpingectomy (risk ratio, 0.22; 95% confidence interval, 0.05-1.02), but this did not reach statistical significance (P=.05).

CONCLUSION

We conclude from these data that salpingectomy is as safe and efficacious as tubal ligation for sterilization and may be preferred, where appropriate, to reduce the risk of ovarian cancer.

Pregnant patients requiring appendectomy: comparison between open and laparoscopic approaches in NY State

INTRODUCTION

Even though acute appendicitis is the most common general surgical condition encountered during pregnancy, the preferred approach to appendectomy in pregnant patients remains controversial. Current guidelines support laparoscopic appendectomy as the treatment of choice for pregnant women with appendicitis, regardless of trimester. However, recent published data suggests that the laparoscopic approach contributes to higher rates of fetal demise. Our study aims to compare laparoscopic and open appendectomy in pregnancy at a statewide population level.

METHODS

ICD-9 codes were used to extract 1006 pregnant patients undergoing appendectomy between 2005 and 2014 from the NY Statewide Planning and Research Cooperative System (SPARCS) database. Surgical outcomes (any complications, 30-day readmission rate, length of stay (LOS)) and obstetrical outcomes (antepartum hemorrhage, preterm delivery, cesarean section, sepsis, chorioamnionitis) were compared between open and laparoscopic appendectomy. Multivariable generalized linear regression models were used to compare different outcomes between two surgical approaches after adjusting for possible confounders.

RESULTS

The laparoscopic cohort (n = 547, 54.4%) had significantly shorter LOS than the open group (median ± IQR: 2.00 ± 2.00 days versus 3.00 ± 2.00 days, p value < 0.0001, ratio = 0.789, 95% CI 0.727-0.856). Patients with complicated appendicitis had longer LOS than those with simple appendicitis (p value < 0.0001, ratio = 1.660, 95% CI 1.501-1.835). Obstetrical outcomes (p value = 0.097, OR 1.254, 95% CI 0.961-1.638), 30-day non-delivery readmission (p value = 0.762, OR 1.117, 95% CI 0.538-2.319), and any complications (p value = 0.753, OR 0.924, 95% CI 0.564-1.517) were not statistically significant between the laparoscopic versus open appendectomy groups. Three cases of fetal demise occurred, all within the laparoscopic appendectomy group.

CONCLUSIONS

The laparoscopic approach resulted in a shorter LOS. Although fetal demise only occurred in the laparoscopic group, these results were not significant (p value = 0.255). Our large population-based study further supports current guidelines that laparoscopic appendectomy may offer benefits over open surgery for pregnant patients in any trimester due to reduced time in the hospital and fetal and maternal outcomes comparable to open appendectomy.

Adnexal masses in pregnancy: an updated review on diagnosis and treatment

Adnexal masses are not common in pregnancy. They are often discovered incidentally during routine ultrasound examinations. In general, 24%-40% of the cases are benign tumors; up to 8% are malignant tumors. Adnexal masses are usually asymptomatic, but sometimes can be responsible for abdominal or pelvic pain. Transvaginal and transabdominal ultrasound is essential to define the morphology of pelvic masses and to distinguish between benign and malignant cases. Magnetic resonance imaging can be a complementary examination when ultrasound findings are equivocal and a useful additional examination to better define tissue planes and relations with other organs. Patient counseling can be challenging because there is no clear consensus on the management of adnexal masses during pregnancy. Treatment options consist of observational management (in case of asymptomatic women with reassuring instrumental findings) or surgery (via laparoscopy or laparotomy). Surgery can be offered as a primary tool when cancer is suspected or when acute complications such as ovarian torsion occur.

Laparoscopic surgery for non-obstetric acute abdomen in pregnancy: A retrospective case series review

BACKGROUND

Laparoscopic techniques have been used during pregnancy by obstetricians since the 1970's, primarily to diagnose and treat ectopic and heterotopic pregnancies. Pregnancy was considered as an absolute contraindication to laparoscopy by surgeons as recently as 1991, and a few still doubt the safety of minimal access in gravid patients. When an emergent operation is indicated, the surgery should not be withheld on the sole basis of patient's gravid state. On the contrary, the alleviation of maternal disease is thought to take priority because the health of the foetus is dependant on the mother.

MATERIALS AND METHODS

This is a retrospective study of a case series of 18 obstetric patients who presented with non-obstetric causes of acute abdomen requiring surgical intervention. Ultrasonography and magnetic resonance imaging (MRI) along with other laboratory investigations were carried out to reach the diagnosis. Laparoscopic surgery was considered as the modality of treatment. All the patients were given the necessary care post-surgery and were followed up till parturition to look for any complications.

RESULTS

The data were analysed considering the presentation, diagnostic variations and the surgical modifications statistically.

CONCLUSION

The decision of surgery should be prompt and should be weighed against complications of conserving the patient. Due to the diagnostic limitations of ultrasonography, MRI should be coupled to confirm the diagnosis. Laparoscopy offers less analgesic requirements and shorter hospital stay. The operative time is highly subjective to the experience and training of the surgeon and the laparoscopic set-up itself.

Laparoscopic Adnexal Detorsion in a 20-Week Pregnant Patient: A Case Report and Literature Review

Adnexal torsion is a cause of severe pelvic pain in reproductive aged women and during pregnancy. Adnexal torsion occurs when there is a complete turn of the ovary, tube, or both resulting in impaired blood flow to the ovary. The diagnosis of adnexal torsion is sometimes challenging due to the enlarged effect of the uterus, the displacement of abdominal and pelvic structures and the nonspecific symptoms in pregnancy. Therefore, prompt diagnosis is essential for better maternal and neonatal outcomes. The gold standard for confirmation and treatment of ovarian torsion is surgery. Laparoscopy and Laparotomy are surgical options with defined risks and benefits. Therefore, choosing the best surgical technique and surgical procedure are of utmost importance to decrease the chances of adverse events intra and postoperatively. Little literature exists regarding the laparoscopic approach of an ovarian torsion during the second trimester. Our case is a 20-week pregnant patient who had a 1080 degree rotation of the left adnexa. She required laparoscopy for adnexal detorsion and had good intraoperative, postoperative, maternal, and neonatal outcomes following management.

Adnexal Torsion in Pregnancy Managed by Laparoscopy Is Associated with Favorable Obstetric Outcomes

STUDY OBJECTIVE

Most cases of adnexal torsion in pregnancy are currently managed by laparoscopy, which may be associated with increased risks for spontaneous abortion and preterm delivery. We sought to evaluate the obstetric outcomes of these women, with emphasis on their live birth rate and gestational age at delivery.

DESIGN

Retrospective cohort study and telephone questionnaire.

SETTING

University-affiliated obstetrics and gynecology department.

PATIENTS

All pregnant women who underwent laparoscopy for adnexal torsion between 2007 and 2017. Their obstetric outcomes were obtained by retrospective review of medical records and a telephone questionnaire.

INTERVENTIONS

Laparoscopy for adnexal detorsion, with or without cyst drainage or cystectomy.

MEASUREMENTS AND MAIN RESULTS

The study cohort included 94 women. Most torsion cases (71, 75.5%) were diagnosed in the first trimester of pregnancy, whereas 21 (22.3%) cases and 2 (2.1%) cases were diagnosed in the second and third trimesters, respectively. Conception was achieved by in vitro fertilization or by ovulation induction in 45 (47.9%) cases. The information on pregnancy outcomes was available for 93 women. Of those, live birth was reported for 86 (92.5%) pregnancies, while 6 (6.5%) women had a spontaneous abortion, and 1 woman experienced an intrauterine fetal death. Five cases of spontaneous abortion were diagnosed in the first trimester, all within 3 weeks of surgery. Preterm delivery before 37 gestational weeks was reported for 18 (19.4%) pregnancies and was significantly associated with twin pregnancy (p = .002) and with conception following in vitro fertilization and ovulation induction (p = .03). On logistic regression analysis, preterm delivery was only associated with twin vs singleton gestation (odds ratio, 6.7; 95% confidence interval, 1.3-34.8; p = .02).

CONCLUSION

The obstetric outcomes of pregnant women who underwent laparoscopy for adnexal torsion are generally favorable. However, there is a risk for preterm delivery, which is primarily associated with multiple gestations.

Minimally invasive gynecologic surgery in the pregnant patient: considerations, techniques, and postoperative management per trimester

PURPOSE OF REVIEW

Nonobstetric surgery is performed in 1 : 200 to 1 : 500 of pregnant women in the United States annually. Previously, many argued that laparoscopy was contraindicated during pregnancy because of concerns for uterine injury and fetal malperfusion. Because surgeons have gained more experience with laparoscopy, it has become the preferred treatment modality for many surgical diseases in the gravid patient.

RECENT FINDINGS

Specific preoperative considerations, intraoperative techniques, and postoperative management per trimester will be reviewed to optimize patient and surgical outcomes.

SUMMARY

The advantages of laparoscopic surgery are similar for pregnant and nonpregnant women. Surgery during pregnancy should minimize risks to both the fetus and the mother. Whenever a pregnant woman undergoes nonobstetric surgery, consultations among her surgical team are important to coordinate management. Both anatomic and physiologic changes related to pregnancy may require modifications in management. Surgeons must be aware of considerations, techniques, and postoperative management used for pregnant patients to optimize outcomes for both the fetus and mother.

The effects of partial amniotic carbon dioxide insufflation in an ovine model

OBJECTIVE

We aim to assess the effect of partial amniotic carbon dioxide insufflation (PACI) at increasing pressures on fetal acid-base, fetal-placental perfusion, and fetal membrane morphology in an ovine model.

METHOD

Pregnant ewes and fetuses were instrumented under isoflurane anesthesia at 105 days gestation (term 145 days) to monitor utero-placental blood flow, fetal and maternal blood pressure, heart rate, and blood gas status. One group (n = 6) was exposed to PACI (unheated dry CO₂ ), involving 10 mm Hg stepwise increases in insufflation pressure (5 to 25 mm Hg), for 80 minutes followed by 20 minutes of desufflation. Un-insufflated controls (n = 5) were monitored for 100 minutes. At postmortem, fetal membranes were collected for histological analysis.

RESULTS

PACI at 25 mm Hg caused severe fetal hypercapnia (PaCO₂  = 143 ± 5 vs 54 ± 5 mm Hg, P < 0.001), acidosis (pH = 6.85 ± 0.02 vs 7.25 ± 0.02, P < 0.001), hypoxia (SaO₂  = 31 ± 4% vs 57 ± 4%, P = 0.01), and reduced uterine artery flow (50 ± 15 vs 196 ± 13 mL/min/kg, P = 0.005) compared with controls. These effects were greater at higher PACI pressures. PACI resulted in leukocyte infiltration in the amnion (1.77 × 10^-5  ± 0.61 × 10^-5 vs 0.38 × 10^-5  ± 0.19 × 10^-5  cells/μm² , P = 0.04) and chorionic membranes (2.94 × 10^-5  ± 0.67 × 10^-5 vs 0.84 × 10^-5  ± 0.42 × 10^-5  cells/μm² , P = 0.01).

CONCLUSION

Higher PACI pressures results in larger disturbances in fetal acid-base, uterine blood flow, and fetal membrane inflammation in sheep. Differences between human and sheep utero-placental structure should be considered.

Laparoscopic appendectomy during the third trimester: Case presentation and literature review

Acute appendicitis is the most common general surgical problem encountered during pregnancy. Laparoscopic appendectomy (LA) is widely accepted as a minimally invasive procedure for acute appendicitis. However, LA during the third trimester is associated with problems, including technical difficulty, risk of preterm delivery, and fetal loss. We successfully managed three cases of LA during the third trimester between 2011 and 2016. None of the cases required conversion to an open procedure, and none of the patients had postoperative complications and/or fetal loss. We reviewed the literature using the PubMED database from 2007 to 2016 to acquire further evidence and identified 6 reports and 17 cases. The conversion rate was 11.8% (2 cases), the complication rate was 6.67% (1 case), and the preterm delivery rate was 20% (3 cases); no fetal loss was observed. Our study and literature review highlights the role of LA as a potentially feasible treatment approach for appendicitis during the third trimester.

Ovarian dysgerminoma in pregnancy: A case report and literature review

BACKGROUND

Dysgerminoma is an uncommon malignant tumor arising from the germ cells of the ovary. Its association with pregnancy is extremely rare; the incidence is about 0.2-1 per 100,000 pregnancies. Because of its infrequency, there are few recommendations regarding its management in pregnancy; therefore, it is important to discuss and summarize the treatment strategy.

CASE

We presented a case of a 23-year-old pregnant woman with a large dysgerminoma originated from the right ovary, which had the unusual coincidence of being associated with an abdominal desmoid tumor simultaneously. We did not find any similar cases published in the PubMed database after 1947. A cesarean section was performed at 34 + 6 weeks gestation secondary to her abdominal pain worsening. The patient delivered a healthy boy and had fertility-preserving surgery, followed by 6 cycles of chemotherapy. This case is compared with 21 other reported cases of pure ovarian dysgerminoma in the literature to evaluate the clinical characteristics, feto-maternal compromise, treatment, long-term survival, and fertility outcome.

CONCLUSION

The treatment strategy in women with ovarian dysgerminoma should be discussed and structured on an individual basis. If pregnancy is desired, surgical intervention undertaken in the second trimester seems to be the first choice. When chemotherapy is indicated, unless delivery can be accomplished within a few weeks of diagnosis, it should not necessarily be delayed until after delivery. Good reproductive function and high survival rate can be achieved in patients treated with conservative surgery and adjuvant chemotherapy.

Adnexal Torsion during Pregnancy: Outcomes after Surgical Intervention-A Retrospective Case-Control Study

STUDY OBJECTIVE

To investigate the pregnancy and neonatal outcomes of surgical treatment for adnexal torsion (AT) during pregnancy.

DESIGN

A retrospective case-control study (Canadian Task Force classification II-2).

SETTING

A tertiary care academic medical center.

MEASUREMENTS AND MAIN RESULTS

The study group included all parturients who underwent surgery for suspected AT during pregnancy from January 2005 to January 2017. The control group included parturients with an uneventful pregnancy matched by maternal age, parity, multiple gestation, and pregnancy complications. The primary outcome was gestational age at delivery. Secondary outcomes were perinatal outcomes and intraoperative and immediate postoperative complications. Among 85 study group patients with suspected AT, 78 (91.7%) underwent laparoscopy and 7 (8.3%) laparotomy. Torsion was diagnosed in 84 patients (98.8%). The gestational age at delivery was similar between the study and control groups (38.7 ± 1.5 vs 38.6 ± 1.6 weeks, respectively; p = .908) as was preterm labor (5.8% in both groups, p = 1.00). There was no significant difference between the study and control groups in pregnancy and neonatal outcomes, including Apgar scores, mean cord blood pH (7.25 ± 0.1 and 7.26 ± 0.08, respectively), and birth weight (3040 ± 473 g and 3115 ± 584 g, respectively). In the study group, the mean gestational age at surgery was 11.2 ± 6 weeks (range, 4-34 weeks). The average operative time was 40.2 ± 22 minutes. In the postoperative follow-up, 3 (3.5%) patients had a first trimester miscarriage. A previous cesarean delivery was a risk factor for ovarian torsion during pregnancy (p = .012).

CONCLUSION

Adnexal detorsion with or without additional surgical procedures during pregnancy did not affect the gestational age at delivery and did not appear to increase fetal or maternal complication rates.

Emergency general surgery in pregnancy

It is often that the acute care surgeon will be called on to evaluate the pregnant patient with abdominal pain. Most of the diagnostic and management decisions regarding pregnant patients will follow the usual tenets of surgery; however, there are important differences in the pregnant patient to be aware of to avoid pitfalls which can lead to complications for both mother and fetus. This review hopes to describe the most common emergencies facing the surgeon caring for the pregnant patient and the latest management options.

Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study

Background

Previous research suggests that non-obstetric surgery is carried out in 1–2% of all pregnancies. However, there is limited evidence quantifying the associated risks. Furthermore, of the evidence available, none relates directly to outcomes in the UK, and there are no current NHS guidelines regarding non-obstetric surgery in pregnant women.

Objectives

To estimate the risk of adverse birth outcomes of pregnancies in which non-obstetric surgery was or was not carried out. To further analyse common procedure groups.

Data Source

Hospital Episode Statistics (HES) maternity data collected between 2002–3 and 2011–12.

Main outcomes

Spontaneous abortion, preterm delivery, maternal death, caesarean delivery, long inpatient stay, stillbirth and low birthweight.

Methods

We utilised HES, an administrative database that includes records of all patient admissions and day cases in all English NHS hospitals. We analysed HES maternity data collected between 2002–3 and 2011–12, and identified pregnancies in which non-obstetric surgery was carried out. We used logistic regression models to determine the adjusted relative risk and attributable risk of non-obstetric surgical procedures for adverse birth outcomes and the number needed to harm.

Results

We identified 6,486,280 pregnancies, in 47,628 of which non-obstetric surgery was carried out. In comparison with pregnancies in which surgery was not carried out, we found that non-obstetric surgery was associated with a higher risk of adverse birth outcomes, although the attributable risk was generally low. We estimated that for every 287 pregnancies in which a surgical operation was carried out there was one additional stillbirth; for every 31 operations there was one additional preterm delivery; for every 25 operations there was one additional caesarean section; for every 50 operations there was one additional long inpatient stay; and for every 39 operations there was one additional low-birthweight baby.

Limitations

We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Many spontaneous abortions will not be associated with a hospital admission and, therefore, will not be included in our analysis. A spontaneous abortion may be more likely to be reported if it occurs during the same hospital admission as the procedure, and this could account for the associated increased risk with surgery during pregnancy. There are missing values of key data items to determine parity, gestational age, birthweight and stillbirth.

Conclusions

This is the first study to report the risk of adverse birth outcomes following non-obstetric surgery during pregnancy across NHS hospitals in England. We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Our observational study can never attribute a causal relationship between surgery and adverse birth outcomes, and we were unable to determine the risk of not undergoing surgery where surgery was clinically indicated. We have some reservations over associations of risk factors with spontaneous abortion because of potential ascertainment bias. However, we believe that our findings and, in particular, the numbers needed to harm improve on previous research, utilise a more recent and larger data set based on UK practices, and are useful reference points for any discussion of risk with prospective patients. The risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery is relatively low, confirming that surgical procedures during pregnancy are generally safe.

Future work

Further evaluation of the association of non-obstetric surgery and spontaneous abortion. Evaluation of the impact of non-obstetric surgery on the newborn (e.g. neonatal intensive care unit admission, prolonged length of neonatal stay, neonatal death).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Laparoscopic surgery for treating adnexal masses during the first trimester of pregnancy

OBJECTIVE:

To evaluate the feasibility and safety of laparoscopic surgery for treating adnexal masses during the first trimester of pregnancy.

STUDY DESIGN:

An observational study of a prospective collection of data of all pregnant women who underwent laparoscopic surgery for adnexal masses during the first trimester of pregnancy between January 1999 and November 2012 at the Obstetrics and Gynecology Department of the Italian Hospital of Buenos Aires, Buenos Aires, Argentina was performed.

RESULTS:

A total of 13 women were included. The median (range) gestational age at the moment of surgical procedure was 7 weeks (range: 5-12 weeks). The main indication of surgery was cyst torsion in four cases (30.7%) and rupture of ovarian cysts in four cases (30.7%). Other indications included persistent ovarian cyst in three patients (23%) and heterotopic pregnancy in two cases (15.3%). Neither surgical complications nor spontaneous abortions occurred in any of the cases and the post-operative period was uneventful in all the cases. No cases of intrauterine growth retardation, preterm delivery, congenital defects, or neonatal complications were registered.

CONCLUSION:

The treatment of complicated adnexal masses by laparoscopic surgery during the first trimester of pregnancy appears to be a safe procedure both for the mother and for the foetus. Additional research on a larger number of cases is still needed to support these conclusions.

Update on the management of non-obstetric acute abdomen in pregnant patients

Acute abdomen is a rare entity in the pregnant patient, with an incidence of one in 500-635 patients. Its appearance requires a quick response and an early diagnosis to treat the underlying disease and prevent maternal and fetal morbidity. Imaging tests are essential, due to clinical and laboratory masking in this subgroup. Appendicitis and complicated biliary pathology are the most frequent causes of non-obstetric acute abdomen in the pregnant patient. The decision to operate, the timing, and the surgical approach are essential for a correct management of this pathology. The aim of this paper is to perform a review and update on the diagnosis and treatment of non-obstetric acute abdomen in pregnancy.

Abdominal emergencies during pregnancy

Abdominal emergencies during pregnancy (excluding obstetrical emergencies) occur in one out of 500-700 pregnancies and may involve gastrointestinal, gynecologic, urologic, vascular and traumatic etiologies; surgery is necessary in 0.2-2% of cases. Since these emergencies are relatively rare, patients should be referred to specialized centers where surgical, obstetrical and neonatal cares are available, particularly because surgical intervention increases the risk of premature labor. Clinical presentations may be atypical and misleading because of pregnancy-associated anatomical and physiologic alterations, which often result in diagnostic uncertainty and therapeutic delay with increased risks of maternal and infant morbidity. The most common abdominal emergencies are acute appendicitis (best treated by laparoscopic appendectomy), acute calculous cholecystitis (best treated by laparoscopic cholecystectomy from the first trimester through the early part of the third trimester) and intestinal obstruction (where medical treatment is the first-line approach, just as in the non-pregnant patient). Acute pancreatitis is rare, usually resulting from trans-ampullary passage of gallstones; it usually resolves with medical treatment but an elevated risk of recurrent episodes justifies laparoscopic cholecystectomy in the 2nd trimester and endoscopic sphincterotomy in the 3rd trimester. The aim of the present work is to review pregnancy-induced anatomical and physiological modifications, to describe the main abdominal emergencies during pregnancy, their specific features and their diagnostic and therapeutic management.

Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients

BACKGROUND

When pregnant patients require surgery, whether to perform an operation open or laparoscopic is often debated. We evaluated the impact of laparoscopy for common general surgical problems in pregnancy to determine safety and trends in operative approach over time.

METHODS

Pregnant patients undergoing appendectomy or cholecystectomy were identified using the National Surgical Quality Improvement Program (NSQIP) database. We analyzed demographics, operative characteristics, and outcomes. Univariate comparison and multivariate regression analysis (MVA) were performed adjusting for confounding factors: age, body mass index (BMI), diabetes, and smoking, and an additional MVA was performed for perforated cases.

RESULTS

A total of 1999 pregnant patients between 2005 and 2012 were evaluated. Of 1335 appendectomies, 894 were performed laparoscopically (LA) and 441 open (OA). For 664 cholecystectomies, 606 were laparoscopic (LC) and 58 open (OC). There were no deaths. For LA versus OA, patient characteristics were not different {age: 27.7 vs. 28.2 years, p = 0.19; diabetes: 1.8 vs. 0.9%, p = 0.24; smoking: 19 vs. 16.1%, p = 0.2} except for BMI (27.9 vs. 28.4 kg/m(2); p = 0.03). LA had shorter operative times (ORT), length of stay (LOS), and fewer postoperative complications compared to OA. In MVA, difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.01), and wound complications (<0.01). MVA was performed for perforated cases alone: LA had equal ORT (p = 0.19) yet shorter LOS (p = <0.001). The majority of LA were performed in the last 4 years versus the first 4 years (61 vs. 39%, p < 0.001). For LC versus OC, patient characteristics were not different: age (28.3 vs. 28.7 years; p = 0.33), BMI (31.4 vs. 33.2 kg/m(2), p = 0.25), diabetes (2.8 vs. 3.5%, p = 0.68), and smoking (21.1 vs. 25.9%, p = 0.4). LC had a shorter ORT, LOS, and fewer postoperative complications than OC. In MVA, the difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.0001), and minor complications (<0.01). In MVA for cholecystitis with perforation, no difference was seen for LOS, ORT, or postoperative complications (p > 0.05). The percentage of LC cases appeared to increase over time (89 vs. 93%, p = 0.06).

CONCLUSION

While fetal events are unknown, LA and LC in pregnant patients demonstrated shorter ORT, LOS, and reduced complications and were performed more frequently over time. Even in perforated cases, laparoscopy appears safe in pregnant patients.

Laparoscopic surgery performed in advanced pregnancy compared to early pregnancy

PURPOSE

The aim of our study was to assess the clinical and obstetric outcomes of laparoscopic surgeries performed during advanced pregnancy compared to those performed in early pregnancy.

METHODS

We retrospectively reviewed all cases of patients who underwent laparoscopic surgery during pregnancy in our institution between 1996 and 2013.

RESULTS

We reviewed cases of 117 pregnant women who underwent laparoscopic surgery during the study period. There were no conversions to laparotomy. 71 surgeries were performed in the first trimester (group 1, mean gestational age 7.7 ± 1.9 weeks) and 46 were performed in the second and third trimesters (group 2, mean gestational age 18.1 ± 4.3 weeks). More patients in group 1 underwent surgery for suspected adnexal torsion (p < 0.001), while more patients in group 2 underwent surgery for presumptive cholecystitis (p = 0.014) and persistent ovarian mass (p = 0.011). The interval between admission and surgery differed significantly between the groups and was longer in group 2 compared to group 1 (18.2 ± 24.0 vs. 6.8 ± 10.6 h, p = 0.001). No difference was found between the two groups regarding surgical complications, histopathological findings and pregnancy outcomes.

CONCLUSION

In our experience, laparoscopic surgery in advanced pregnancy was found to be feasible and safe as in early pregnancy, without any adverse effects on pregnancy outcome.

Abdominal surgery in pregnancy--an interdisciplinary challenge

BACKGROUND

Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach.

METHOD

This review is based on pertinent articles retrieved by a selective search in the PubMed database.

RESULTS

The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31-2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78-1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth.

CONCLUSION

Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Management of pregnant patients undergoing general surgical procedures

Pregnant patients have a 0.2% to 0.75% chance of developing a medical condition that requires a general surgical intervention during pregnancy. To safely and appropriately care for patients, surgeons must be cognizant of the maternal physiologic changes in pregnancy as well as of the unique risk to both mothers and fetuses of diagnostic modalities, anesthetic care, operative intervention, and postoperative management. Surgeons can be assured that, if these risks are understood and considered, operating during pregnancy, even in the abdomen, can be safely undertaken.

Acute abdomen in pregnancy due to isolated Fallopian tube torsion: The laparoscopic treatment of a rare case

In the last years, operative laparoscopy became a standard approach in gynaecology and general surgery. Even in pregnancy its use is becoming more widely accepted. In fact, it offers advantages similar to those in no pregnant women, associated with good maternal and fetal outcomes. Around 0.2% of pregnant women require abdominal surgery. The most common indications of laparoscopy in pregnancy are cholelithiasis complications, appendicitis, persistent ovarian cyst and adnexal torsion. Authors describe a very rare case of acute abdomen due to isolated Fallopian tube torsion in a 24^th weeks pregnant woman, managed by laparoscopic salpingectomy.

Appendicitis: changing perspectives

Neoplasms are an uncommon finding after appendectomy, with malignant tumors occurring in less than 1% of the surgical specimens, and carcinoid being the most frequent malignancy. A negative or inconclusive ultrasound is not adequate to rule out appendicitis and should be followed by CT scan. For pregnant patients, MRI is a reasonable alternative to CT scan. Nonoperative treatment with antibiotics is safe as an initial treatment of uncomplicated appendicitis, with a significant decrease in complications but a high failure rate. Open and laparoscopic appendectomies for appendicitis provide similar results overall, although the laparoscopic technique may be advantageous for obese and elderly patients but may be associated with a higher incidence of intraabdominal abscess. Preoperative diagnostic accuracy is of utmost importance during pregnancy because a negative appendectomy is associated with a significant incidence of fetal loss. The increased morbidity associated with appendectomy delay suggests that prompt surgical intervention remains the safest approach. Routine incidental appendectomy should not be performed except in selected cases. Interval appendectomy is not indicated because of considerable risks of complications and lack of any clinical benefit. Patients older than 40 years with an appendiceal mass or abscess treated nonoperatively should routinely have a colonoscopy as part of their follow-up to rule out cancer or alternative diagnosis.